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SAN JOAQUIN LOCAL HEALTH DISTRICT P rmit o. <br /> OFFICE USE: 1601 E. Hazelton Ave.', Stockton, CA 95205 <br /> FOR O Telephone: (209). 466-6781 `tS <br /> -�s �T _ Dat ISsFd� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ires 1 Year From Date Issued <br /> 4 Complete ' 111 Tri pl'xi cafe <br /> b made to the San Joaquin focal Health District for a permit to construct A <br /> Application is hereby lication is made in compliance with San . <br /> and/or install the work herein described. Thistapp <br /> �� Caunt Ordinance filo. 1862 and the Rules and Regulations -of the San Joaquin Local Health <br /> oaqij <br /> District. CITY/TOWN <br />; EXACT STREET ADDRESS Phone____ - - --- <br /> t � <br /> Owner's Name. City <br /> AddressLivens f Phone , y --- <br /> � <br /> . Contractor' s Name <br /> `.IS CERTIFICATE OF WORKt`sAPJ'S COMPENSATIO"! INSURANCE ON FILE WITH SJLHD? YES AISO------- <br /> ITYPE OF WORK (Check) : NEW WELL Ug—DEEPEN ❑ RECONDITION ❑ <br /> DESTRUCTION El �. <br /> WELL CHLORINATION WELL PUMP REPAIR ANDO0 NT SMP REPLACEMENT 0 <br /> PUMP INSTALLAION <br /> DISTANCE .T_O�NEAREST: SEPTIC-TANK ct L LDER LINECESSPOOL/SEEPAGEY;P;IT -^ L" OTHER <br /> SEWAGE DISPOSA <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL-------- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. °f Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing i <br /> ublic - Driven - Gauge of Casing f <br /> Domestic/public Gravel Pack Depth of Grout Seal <br /> Irrigation Type of Grout <br /> Cathodic Protection _Rotary <br /> Disposal Other Other Information <br /> E � Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor H.P. r` <br /> + Type of Pump ` <br /> ' PUMP REPLACEMENT: Q State Work Done ! <br /> PUMP REPAIR: ❑State _Work. Done _ _ _ <br /> Approximate Depth <br /> DESTRUCTION .OF WELL: Well Diameter <br /> Describe Materia and Procedure - _ <br /> f <br /> lication and that the work will be done in accord'ar <br /> I hereby certify. that I have prepared thiapp1 <br /> `w.ith San Joaquin County Ordinances, State._Laws and Rules and Regulations of the,San Joaquin Loc. <br /> ,�Calth District. Home owner or licensed a`§entls signature certifies the following: <br /> "I certify that in the performance of the *w0rk for which become subje'ct'to 'WQrkman's- Compednsationall <br /> not employ any iperson `i n s-uch -ma-nner as to <br /> laws of California." NSPECTION. <br /> WILL CL FOR A GROUT.-INSPECTION PRIOR -•0 GROUTING AND A FINAL I <br /> ALT. d <br /> p - TITLE:--C -tufa DATE <br /> IGNED DR .W P OT PL N ON REVERSE SIDE <br /> FOR DEPA MENT U ONLY <br /> P4iAS E I4• = ___..,,�D.AT.E- <br /> APPLICATION ACCEPTED BY, <br /> ADDITIONAL COMMENTS'. ,'-.` 'r <br /> PHASE FII GROUT INSPECTION PHASE �III FINAL INSpECTION� <br /> �� <br /> INSPECTION BY DATE <br /> INSPECTION BY C DATE <br /> ~�. .� ...»... <br />